Provider Demographics
NPI:1336168053
Name:LEWIS, RACHEL ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:ELLEN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9371
Mailing Address - Country:US
Mailing Address - Phone:315-786-7300
Mailing Address - Fax:
Practice Address - Street 1:1575 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9371
Practice Address - Country:US
Practice Address - Phone:315-786-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191378-1207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01445234Medicaid
NY55589CMedicare ID - Type UnspecifiedPROVIDER IDENTIFICATION
NY01445234Medicaid